Center for Reconstructive Urethral Surgery Arezzo - Italyurethralcenter.it/pdf/Letture_Barbagli/BERLINO.pdf · Center for Reconstructive Urethral Surgery. Prevalence of anastomotic

Guido Barbagli

Arezzo - Italy

Center for Reconstructive Urethral Surgery

E-mail: [email protected] Website: www.urethralcenter.it



Berlin – Germany

22nd Annual EAU Congress

March 21 - 24, 2007

Which type of urethroplasty - a critical

overview of results and complications


The surgical technique

for the repair of penile

urethral strictures is

selected according to

stricture etiology

Penile urethroplasty


Etiology of penile urethral stricturesin 404 patients

Failed hypospadias repair 40%

Lichen sclerosus 40%

Trauma

Instrumentation

Catheter

Infection

Other causes

20%

80%

Barbagli 2006, unpublished data


trauma, instrumentation, catheter, infection and other causes

In patients with penile urethral strictures due to:

penis is normal


McANINCH

JORDANORANDI

One-stage urethroplasty using dartos

fascial flap with skin island


Orandi


Orandi


Result








Jordan


Jordan


Jordan


Jordan


McAninch


McAninch


McAninch


McAninch


McAninch


Possible complications following flap

urethroplasty

penile hematoma skin necrosis

fistula penile-glans torsion


One-stage urethroplasty using dorsal

inlay buccal mucosal graft





meatal stenosis fistulainfection

Possible complications following graft

urethroplasty


failed hypospadias

repair

lichen sclerosus

In patients with penile urethral strictures due to:

penis is abnormal


Multi-stage urethroplasty using buccalmucosal graft


First stage




10-39% of patients showed contracture or scarring of the initial graft, requiring

new grafting procedures

These repeated surgical revisions might have a tremendous psychological impact

on the patient

Possible complications following the

first stage of urethroplasty

Barbagli et al., Eur Urol, 2006


Second stage




Possible complications following the

second stage of urethroplasty

fistula glans dehiscence meatal stenosis

30% of patients showed complications following the second stage of

urethroplasty, requiring surgical revision

Barbagli et al., Eur Urol, 2006


The literature dealing with this argument is still terribly

confused and does not furnish reliable interpretation of the

available data

Patients with penile urethral stricture disease are treated with

so many various surgical approaches that it is really impossible

to evaluate and standardize the long-term outcome of all these

techniques

Evaluation of surgical outcome


Which type of

urethroplasty ?

Bulbar urethroplasty


Substitution urethroplasty

dorsal onlay graft urethroplasty

ventral onlay graft urethroplasty

Anastomotic urethroplasty

end-to-end anastomosis

augmented roof-strip anastomosis


Anastomotic or substitutionurethroplasty ?

0

18%

complications *

019 ( 100% )buccal graft19

2 ( 70% )26 ( 83% )end-to-end28

failuresuccesstype of repairpatients

* penile chordee or erectile dysfunction

Al-Qudah et al., J Urol, 2006


Which type of substitution

urethroplasty

ventral dorsal

?


85%4217Barbagli et al.

J Urol 2005

90%\11Delvecchio et al.

J Urol 2004


J Urol 2004

88%6042Andrich et al.

B J U Int 2001

100%1912Iselin et al.

J Urol 1999


J Urol 1998

success ratemean follow-uppatientsauthors

Dorsal onlay graft urethroplastypublished results



J Urol 2005

88%5018Kellner et al.

J Urol 2004

90%4760Elliot et al. J Urol 2003

94%2553Kane et al.

J Urol 2002

successratemean follow-uppatientsauthors

Ventral onlay graft urethroplastypublished results


J Urol 2005


Ventral Dorsal

83% success 85% success

Results

Lateral

83% success


Results

J Urol 2006


Distal anastomotic ring


Proximal anastomotic ring


Distal and proximal anastomotic rings


ring siteanastomotic

ring

entire

grafted

area

4 distal

6

proximal

9%11%80%107total

1 proximal8%8% 84%12augmented end-to-end urethroplasty

with buccal mucosa

2 distal

3 proximal10%6%84%50

buccal mucosa onlay graft

urethroplasty

2 distal

2 proximal8%17% 73%45dorsal onlay skin graft urethroplasty

type of failure

success

ratepatients

type of urethroplasty

substitute material

Anastomotic rings after bulbarurethroplasty


Prevalence of anastomotic rings following bulbar urethroplasty

313187%381Total

S

dilation (3)

urethrotomy (2)

none (3)

\892%buccal mucosa100Abouassaly et al.

J Urol 2005

Sdilation\194%pedicled skin with

buccal mucosa18

Berglund et al.

J Urol 2004

Surethrotomydistal387%buccal mucosa23Kellner et el.

J Urol 2004

Surethrotomydistal490%buccal mucosa60Elliot et al.

J Urol 2003

Sdilation

urethrotomy\1279%

buccal mucosa

and other122

Chapple et al.

J Urol 2002

Sdilation (1)

urethrotomy (1)

distal (1)

proximal (1)293%

skin (26)

buccal mucosa (3)29

Guralnick et al.

J Urol 2001

Sdilationproximal197%skin (27)

buccal mucosa (2)29

Iselin et al.

J Urol 1999

outcometreatmentsiteringssuccess

ratesubstitute material

patientsauthors


Treatment of the anastomotic ring

Internal urethrotomy


Conclusion

Reconstructive surgery for urethral strictures is continually

evolving and the superiority of one approach over another is

not yet clearly defined

The reconstructive urethral surgeon must be fully able in the

use of different surgical techniques to deal with any condition

of the urethra at the time of surgery


Madonna del Parto - Piero della Francesca

Monterchi - Arezzo


Documents

Center for Reconstructive Urethral Surgery Arezzo - Italyurethralcenter.it/pdf/Letture_Barbagli/BERLINO.pdf · Center for Reconstructive Urethral Surgery. Prevalence of anastomotic